The US healthcare system is at a tipping point. Regulatory pressure is increasing. Patient expectations are rising. Payers and providers are being asked to deliver more value with fewer resources. At the center of this shift is data. How it’s accessed, how it’s shared, and how it’s used to drive better decisions.
As we look ahead to 2026, 1upHealth leadership expects a step change, not incremental improvement. Interoperability will move from promise to practice. Clinical data will begin to reshape payment. Patients will gain real digital leverage. And health plans will lead the next phase of infrastructure modernization.
Claims and Clinical Data Finally Come Together
Dr. Donald Rucker, Chief Strategy Officer at 1upHealth, believes 2026 will be a turning point in how the industry thinks about claims.
“2026 will likely see the rethinking of how we handle claims. American healthcare does not provide value for dollar, and much of that comes from the disconnect between what is charged and what is offered.”
Today’s claims systems rely heavily on isolated CPT and ICD codes, with minimal insight into whether the care delivered was clinically appropriate. That gap has long limited the industry’s ability to measure value.
“The future, enabled by the FHIR data standard, means we will see much more clinical data in the payment system and likely less reliance on isolated CPT4 and ICD10 codes in the search for value,” Rucker says. “Electronic prior authorization is providing the first glimpse into richer interactions between clinical data and the claims process.”
In 2026, claims will no longer stand alone as financial artifacts. They’ll increasingly be informed by clinical context, enabling more accurate determinations, better alignment with outcomes, and a clearer path toward value-based care.
Politics, Policy, and Patient Digital Control
Policy decisions will continue to shape the pace and direction of change. Dr. Rucker notes that political dynamics heading into and following the mid-term elections will directly influence healthcare priorities.
“Mid-term election battlelines will define healthcare forces for 2026. Increasingly, ACA plans are being seen as an unsatisfactory approach to care for folks outside of CMS and employer plans.”
Despite differing policy approaches, one outcome is clear. Patients will play a more active digital role in managing their healthcare data.
“What we can predict with clarity is that there will be more digital involvement by patients as APIs mature and new CMS priorities are implemented,” Dr. Rucker explains.
This shift has implications across the ecosystem. Providers will be expected to participate more fully in data exchange, not just for compliance, but because value-based care success increasingly depends on access to complete clinical data.
“Providers will have to participate in providing clinical data to payers because payer success requires more than just financial claims data,” Don says. “CMS-0057 Access APIs will be the channel for digital control of healthcare, so organizations should be thinking now about how they want to engage in these data flows starting in January 2027.”
2026 as the Year of Payer-Led Interoperability
From a commercial and operational perspective, Nolan Kelly, Chief Revenue Officer at 1upHealth, sees 2026 as an unprecedented year of interoperability execution.
“2026 will bring us the most significant interoperability progress the industry has experienced within a single calendar year due to CMS mandates on health plans,” Nolan says.
As plans operationalize regulatory requirements, the impact will be tangible. Manual processes that have slowed care and increased administrative burden will begin to give way to automation.
According to Nolan, “Throughout the year, we will see a massive shift across the payer space, with more plans putting systems into production to automate prior authorization determinations without manual intervention.”
Data liquidity will also improve across transitions of care and coverage.
“By the end of 2026, most health plans will be able to share data downstream to a member’s new health plan and receive data from a member’s former health plan,” Nolan explains. “The majority of providers will be able to pull full claims and clinical data directly from health plans via on demand FHIR APIs.”
These payer-led infrastructure advancements will not just meet regulatory requirements. They will establish the foundation for innovation in 2027 and beyond.
Preparing for What Comes Next
2026 will not be a year of experimentation. It will be a year of significant change. Organizations that invest now in modern, standards-based data infrastructure will be positioned to lead. Those that treat interoperability as a checkbox will struggle to keep pace.
Healthcare is moving toward a system where data flows continuously, decisions are informed by clinical context, and patients have meaningful digital access and control. 2026 is when that future starts to become operational reality.To speak to one of our experts about modernizing your interoperability strategy, contact us.